Dr Santos is a psychiatrist whose practice focuses on combining psychotherapy and pharmacotherapy to achieve improved outcomes. He graduated from Xavier University, Ateneo De Cagayan and earned both his degree in Nursing and Medicine. After completion of his post-graduate internship and passing the Physician Licensure examination, he pursued further studies. He completed his residency training in Psychiatry at Southern Philippines Medical Center-Institute of Psychiatry and Behavioral Medicine and served as a chief resident Physician in his final year. At the moment, he is continuing further training in Cognitive Behavioral Therapy under the online program of Beck Institute. INFORMED CONSENT TO RECEIVE PSYCHIATRIC EVALUATION AND TREATMENT By accepting the booking confirmation, I acknowledge that I am voluntarily giving my informed consent to receive psychiatric evaluation and treatment from Dr. Santos. I agree that this consultation is for the improvement of my mental health and well-being. Moreover, I understand that this evaluation shall NOT be used for medicolegal purposes. 1. CONFIDENTIALITY. I agree to share my personal data with Dr. Santos and his clinic staff to facilitate the scheduling of my consultation and for billing purposes. I understand all discussions and records are confidential to the extent permitted by law. Information regarding my consultation or the content of our conversations will not be shared without my consent unless permitted by law. However, there are situations that Dr. Santos would be permitted or required by law to disclose without your consent, including but no limited to the following: a. Information may be disclosed to other members of the health care team to facilitate the delivery of professional services to you; b. Mental health information may be disclosed if such disclosure is necessary to initiate or seek emergency hospitalization of the client or to otherwise protect the client or another individual from a substantial risk of imminent and serious physical injury; c. Information may be disclosed to comply with laws regarding the reporting of sexual abuse, abuse, neglect, or exploitation by another for minors or other at-risk populations (e.g. elderly and mentally and physically vulnerable populations); and, d. Information may be disclosed when it is required by the court. Furthermore, in compliance with the Data Privacy Act of 2012, I agree not to take any picture or video when inside the clinic so as to respect the privacy of other clients. I also agree not to record in video or audio format nor divulge the details of my consultation. 2. MEDICATION. Dr. Santos will recommend medications that can be used in treatment as deemed necessary. He will also discuss the indications and potential side effects of these medications. I agree that I will not share my medication with anyone else. I also agree that I will not receive other medications from other healthcare professionals without first informing Dr. Santos. I understand that alcohol and other drugs may compromise my treatment and make my symptoms worse. Moreover, combining alcohol or opiates with benzodiazepines (like clonazepam and alprazolam) could be dangerous and potentially fatal. Hence, I commit to abstaining from these substances while in treatment. 3. MISSED APPOINTMENTS/CANCELLATIONS/LATE ARRIVAL. If I am unable to make a scheduled appointment, I will call to cancel this appointment at least twenty-four (24) hours before the appointment. Otherwise, I will be charged for the appointment. If I fail to show for three or more appointments without notice, or I do not follow up as recommended by Dr. Santos, I may be referred elsewhere for services. I understand that a “no show” is defined as any of the following: missing an appointment without notifying ahead, canceling an appointment with less than twenty-four (24) hours’ notice, or coming late to an appointment. If I arrive fifteen (15) minutes late to an appointment, I understand that my appointment may be cancelled and I may be charged a “no show” fee equivalent to the consultation fee. 4. URGENT/EMERGENT CONCERNS. I understand that I am availing an outpatient service that does not cater to urgent or emergent psychiatric concerns. In case of an emergency, such as when there is a significant risk of imminent and serious physical injury to myself or another individual, I understand that my legal guardian and I shall be responsible for taking me to the nearest emergency room. Dr. Santos will not be liable in such situation. 5. ADMISSION. I understand that admission may be recommended as deemed necessary by Dr. Santos. This may be indicated if there is a threat to my safety or to other individuals, if I am unable to take care of myself, or if there is a need for diagnostic services, among others. I understand that Dr. Santos will discuss the indications for recommending admission to me and to my legal guardian. If my legal guardian and/or I refuse admission, I understand that I will need to sign a waiver. Dr. Santos will not be liable in such situation. 6. FEES. I understand that a fee will be charged for every consultation and for additional requests. I understand that I need to pay the fee in advance if I want to reserve a slot for consultation. Fees are as follows: initial appointment (60-90 minutes): Php 3,000.00 and follow-up appointment (30-60 minutes): Php 2,000.00. Additional fees may also be charged for services, such as prescription of regulated/S2 requiring drugs (Php 300.00) requesting for Medical Certificate or Abstract (Php 500.00) and Psychiatric Report ([Not for Medicolegal Use] Php 1,000.00) and signing of Insurance Claim (Php 500.00). These fees can be paid either by cash or by e-wallet or bank transfer. A 20% discount shall be given for Persons with Disability and Senior Citizens upon presentation of their valid ID. 7. TERMINATION OF SERVICES. I understand that I may decline further participation or recommended treatment at any time. I also understand that my psychiatric care may be terminated, and I may be referred to another psychiatrist if: a. I do not follow the treatment recommendations of Dr. Santos, including referrals, taking medications as prescribed, and following up in the recommended time frame. b. I do not adhere to the patient responsibilities (including acting in a courteous and respectful manner in all interactions). I have read this description of services and understand and consent to these policies. I understand that I have an opportunity to discuss my questions regarding the psychiatric treatment services with Dr. Santos. I understand that there are potential risks and benefits associated with psychiatric treatment. I have the right to make decisions about the psychiatric treatment services I receive, to refuse the psychiatric treatment services, and to revoke this consent at any time except to the extent services have already been provided. Based on the information above, I voluntarily consent to receive psychiatric evaluation and treatment from Dr. Santos. Note: 1. Minors must be accompanied by a parents, relatives, or legal guardian during consultation. 2. Overtly aggressive, actively suicidal or those with recent attempt must seek consult immediately to the Emergency room for prompt management. 3. Depending on the influx of patients, Dr. Santos may see you earlier or later, but rest assured that each of you will receive the best care he can provide. Thank you and Godbless!